Pseudoaneurysm Formation due to Popliteal Artery Injury Caused by Drilling during Medial Opening Wedge High Tibial Osteotomy

We report a case of 53-year-old woman with an injured popliteal artery due to excessive drilling with a drill bit during medial opening wedge high tibial osteotomy (MOWHTO). Pseudoaneurysm was diagnosed three days after surgery and confirmed by urgent computed tomography (CT) angiography. Open vascular surgery with resection of the perivascular hematoma and end-to-end anastomosis using ipsilateral saphenous vein interposition graft was performed. CT angiography at 8 months postoperatively showed that blood flow was maintained without obstruction of the graft site and active dorsiflexion of the foot was possible. To reduce neurovascular injury during MOWHTO, it is important not to drill the far cortex at the proximal part of the osteotomy site when using a drill bit, and the metal should be positioned posteromedially as much as possible.

Prophylaxis for Venous Thromboembolism Following Total Knee Arthroplasty: A Survey of Korean Knee Surgeons

PURPOSE: The purpose of this study is to provide information on the actual status and prevailing trend of prophylaxis for venous thromboembolism (VTE) following total knee arthroplasty (TKA) in South Korea. MATERIALS AND METHODS: The Korean Knee Society (KKS) developed a questionnaire with 6 clinical questions on VTE. The questionnaire was distributed to all members of KKS by both postal and online mail. Participants were asked to supply details on their specialty and to select methods of prophylaxis they employ. Of the total members of KKS, 27.9% participated in the survey. RESULTS: The percentage of surgeons who routinely performed prophylaxis for VTE was 60.4%; 19.4% performed prophylaxis depending on the patient's health condition; and the remaining 20.2% never implemented prophylaxis after surgery. The common prophylactic methods among the responders were compression stocking (72.9%), pneumatic leg compression (63.3%), perioral direct factor Xa inhibitor (46.9%), and low-molecular-weight heparin (39.5%). For the respondents who did not perform prophylaxis, the main reason (51.5%) was the low risk of postoperative VTE considering the low incidences in Asians. CONCLUSIONS: The present study involving members of the KKS will help to comprehend the actual status of VTE prevention in South Korea. The results of this study may be useful to design VTE guidelines appropriate for Koreans in the future.

Arthroscopic Bioabsorbable Screw Fixation of Unstable Osteochondritis Dissecans in Adolescents: Clinical Results, Magnetic Resonance Imaging, and Second-Look Arthroscopic Findings

BACKGROUND: This study aimed to evaluate the clinical and radiological outcomes of arthroscopic bioabsorbable screw fixation in osteochondritis dissecans (OCD) in adolescent patients with unstable lesions causing pain. METHODS: The study included 11 patients (10 males and 1 female) with OCD who underwent arthroscopic bioabsorbable screw fixation between July 2007 and February 2014 and were available for follow-up for more than 12 months. The mean age at diagnosis was 16.3 years (range, 11 to 19 years), and the average follow-up period was 51 months (range, 12 to 91 months). Clinical results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm knee score, and International Knee Documentation Committee (IKDC) score measured before surgery and at follow-up. Functional evaluation was made using the Tegner activity scale. Magnetic resonance imaging (MRI) and second-look arthroscopy were performed at the 12-month follow-up. RESULTS: Between the preoperative assessment and follow-up, improvements were seen in the KOOS (range, 44.9 to 88.1), Lysholm knee score (range, 32.6 to 82.8), and IKDC score (range, 40.8 to 85.6). The Tegner activity scale also improved from 2.8 to 6.1. Based on postoperative MRI, there were eight Dipaola grade I cases and three grade II cases. No complications due to fixation failure developed in any case. Second-look arthroscopy at 12 months postoperatively revealed that the lesion was covered with cartilage in all cases. CONCLUSIONS: For unstable OCD lesions causing pain in adolescents, arthroscopic bioabsorbable screw fixation provided favorable outcomes with reduced pain and restoration of movement. Therefore, it should be considered as an effective treatment for OCD.

The Results of All-Inside Meniscus Repair Using the Viper Repair System Simultaneously with Anterior Cruciate Ligament Reconstruction

BACKGROUND: Meniscus tears are commonly associated with anterior cruciate ligament (ACL) ruptures. It is essential to repair meniscal tears as much as possible to prevent early osteoarthritis and to gain additional stability in the knee joint. We evaluated the results of arthroscopic all-inside repair using the Meniscal Viper Repair System (Arthrex) on meniscus tears simultaneously with ACL reconstruction. METHODS: Nineteen out of 22 patients who were treated with arthroscopic all-inside repair using the Meniscal Viper Repair System for meniscus tear associated with ACL rupture were evaluated. ACL reconstructions were performed at the same period. The mean follow-up period was 16.5 months (range, 12 to 24 months). The clinical results of the meniscus repair were evaluated by symptoms (such as catching or locking), tenderness, effusion, range of motion limitation, and the McMurray test. Clinical success was defined by negative results in all five categories. The Hospital for Special Surgery (HSS) score was evaluated. Objective results were evaluated with secondary look arthroscopy or magnetic resonance imaging (MRI). The MRI results were categorized as completely repaired, incompletely repaired, and failure by Henning's classification. The results of second-look arthroscopy were evaluated with the criteria of meniscal healing. RESULTS: The clinical success rate was 95.4% and the HSS scores were 93.9 +/- 5.4 at the final follow-up. According to Henning's classification, 15 out of 18 cases showed complete healing (83.3%) and two cases (11.1%) showed incomplete healing. Seventeen out of 18 cases that underwent second-look arthroscopy showed complete healing (94.4%) according to the criteria of meniscal healing. Only one case showed failure and the failure was due to a re-rupture at the sutured area. Complications of ACL reconstruction or meniscus repair were not present. CONCLUSIONS: The results demonstrate that arthroscopic all-inside repair using the Meniscal Viper Repair System is an effective treatment method when it is performed simultaneously with ACL reconstruction.

Comparison of Clinical Results and Second-Look Arthroscopic Findings of Remnant Preserving versus Non-Remnant Preserving Technique after Anterior Cruciate Ligament Reconstruction Using Achilles Allograft / 대한정형외과학회잡지

PURPOSE: This study was conducted for evaluation of clinical uses of anterior cruciate ligament (ACL) reconstruction with an Achilles allograft using the remnant technique by comparison and analysis stability, functional assessment and results of second-look arthroscopy between the remnant technique and the non-remnanat technique. MATERIALS AND METHODS: A total of 48 patients who underwent ACL reconstruction using an Achilles allograft were selected and divided into two groups depending on the presence of remnant. The preserving group included 26 patients and non-preserving group included 22 patients. The two groups were compared and analyzed with regarding to stability (Stress view Lachman test, pivot shift test), functional assessment (International Knee Documentation Committee, Lysholm score, Tegner score, single hoop test, shuttle turn, carioca test), and the result of second-look arthroscopy (study design: prosepective cohort study). RESULTS: In the final result, the remnant group showed significant improvement in the Tegner and carioca tests compared with the non-remnant group (p<0.05). In second-look arthroscopy, the remnant group showed better coverage of synovium (p<0.05). CONCLUSION: ACL reconstruction with an Achilles allograft using the remnant technique showed better results in functional assessment and finding in second-look arthroscopy compared with the non-remnant technique group.

Mid-term Results of Single-Radius Cruciate Retaining Total Knee Arthroplasty: Minimum 5 Year Follow-up

PURPOSE: The single-radius design of the knee implant was introduced to improve the results of total knee arthroplasty (TKA) by reducing maximum extensor forces, and it also represents more physiologic quadriceps force pattern, which could have a positive effect on knee function after TKA. We studied mid-term results of single-radius designed cruciate retaining (CR) TKA. MATERIALS AND METHODS: We analyzed the functional improvement and radiological osteolytic pattern after TKA using the single-radius Scorpio CR prosthesis. TKA was performed on 102 knees. The mean follow-up period was 73.8 months. For clinical assessment, the range of motion (ROM), Harris hip score, and functional outcome score were obtained preoperatively and at last follow-up. RESULTS: The average ROM was 100.2degrees preoperatively and 121.7degrees at last follow-up. The average knee score was 59.2 points preoperatively and 92.9 points at last follow-up. The average functional outcome score was improved from 51.9 points preoperatively to 85.4 points at last follow-up. Radiolucency was observed in four knees but all were non-progressive lesions smaller than 2 mm. CONCLUSIONS: The clinical outcome of TKA using the single-radius CR prosthesis was good during the mid-term follow-up and the incidence of osteolysis was very rare.

Infection Following Total Knee Arthroplasty

For most orthopedists, total knee arthroplasty (TKA) has been regarded as the most effective surgery for patients with severe knee diseases. Though seldom occur, postoperative infection certainly remains one of the most devastating and dreaded complications of TKA. Thus, careful and early diagnosis is needed. After diagnosis, categorize the infection type and choose a rightful and sequential step of treatment are recommended.

The Mid-Term Results of High-Flex Total Knee Arthroplasty: Minimum 5-Year Follow-Up Results / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate the mid-term results of high-flexion total knee arthroplasty. MATERIALS AND METHODS: We retrospectively reviewed 77 patients who underwent 119 total knee arthroplastys using high-flexion implants (LPS-flex(R) , Zimmer, Warsaw, IN, USA) from November 2004 to June 2006. The mean age was 67.3 years (range, 54-83 years), and the average follow-up duration was 71.1 months. We assessed preoperative and last follow-up functional outcomes with ranges of motion (ROM) and the Hospital for Special Surgery (HSS) score and investigated their ability to squat, sit cross-legged knee, kneel, or stand up from the floor or a chair at the final follow-up. The Knee Society Radiographic evaluation and scoring system was used for radiologic evaluation. RESULTS: The mean ROM increased from 104.7degrees preoperatively to 129.8degrees postoperatively at the final follow-up. The average HSS score improved from 42.7 points preoperatively to 93.5 points postoperatively. At the final follow-up, 33 patients (42.8%) were able to squat; 75 patients (97.4%) were able to sit cross-legged; 27 patients (35.0%) were able to kneel; 45 patients (58.4%) were able to stand up from the floor and 73 patients (94.8%) were able to stand up from a chair. Six cases encountered stiff knees as a complications, and were treated with manipulation procedures. 1 mm radiolucent lines were detected in 5 cases, but none of them were progressive. CONCLUSION: We believe that the hyperflexion implant itself is not a cause of early loosening. Research on reasons regarding early loosening and long-term follow-ups will be needed.

Proprioceptive and Knee Joint Kinematics for Comparison of Remnant Preserved versus Non-remnant Anterior Cruciate Ligament Reconstruction Using Achilles Allograft / 대한스포츠의학회지

The purpose of remnant preserving technique in anterior cruciate ligament (ACL) reconstruction is to preserve mechanoreceptor and accelerate revascularization. In this study, we compared a group who underwent remnant preserving technique using Achilles tendon allograft with the other group of conventional ACL reconstruction in terms of proprioception, kinematic analysis, knee strength test and dynamic postural stability. Twenty-four patients were followed up for longer than 12 months after ACL reconstruction. They were separated into two groups; remnant preserving group (n=12) and non-remnant group (n=12). Proprioception test was conducted through joint position sense (JPS) and threshold to detection of passive motion. The remnant preserving group showed significantly less difference from the normal side than the non-remnant group. In kinematic analysis, there was statistically significant difference in peak flexion angle during the swing phase. However the 60degrees JPS, knee strength test, performance capacity test and dynamic postural stability did not showed the significant difference. Remnant preserving technique of ACL reconstruction was meaningful in preserving proprioception and the result showed akin to the unaffected gait.

The Histologic Mapping of Sensory Innervation in the Human Anterior Cruciate Ligament / 대한스포츠의학회지

Recently, rising curiosity on remnant preservation technique of anterior cruciate ligament (ACL) reconstruction, there is much interested in being and distribution of the mechanoreceptor of ACL. So, we performed histologic analyzing and mapping of sensory nerve fiber of the human ACL in this study. Total of 20 anterior cruciate ligaments were obtained from total knee replacement. Each ACL samples was divided into seven specimens; tibial insertion site, mid transitional site, femoral insertion site, and in between the sites, and total of 140 tissue samples were stained with hematoxylin-eosin and immunohistochemical, and observed with light microscope. Five hundred thirty-four fine neuroparticle structures, Ruffini corpuscles, and free nerve endings were observed in 20 ACL samples. The mean of fibers observed were 1.88, 1.71, 1.15, 1.08, 1.15, 1.55, and 1.82, respectively from tibial insertional site to femoral insertional site. With immunohistochemical stain, S-100 protein was strong positive at nerve cells, but was weak positive or negative at neurofilament. Mapping of sensory nerve distribution were done based on the results. We identified the mechanoreceptor of the human ACL using optical and immunohistochemical methods and mapped the histologic distribution of that.

The Management of Knee Dislocation and Multiple Ligament Injuries / 대한스포츠의학회지

Multiple ligament injuries of the knee means more than two ligament injuries, using as an analogue of the knee dislocation. The first priority in the early diagnosis and treatment of the knee dislocation is a vascular evaluation of extremity and careful neurovascular examination should be done firstly. It is common opinion in the treatment of multiple ligament injuries that surgical treatment is superior to conservative treatment. Especially, early ligament repair or reconstruction and aggressive rehabilitation are recommended in young active patients.

Outcome of Isolated Tibial Polyethylene Insert Exchange after Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: We investigated the short term outcomes of isolated tibial polyethylene insert exchange after revision total knee arthroplasty. MATERIALS AND METHODS: We selected 18 cases from 17 patients among the 20 cases from 19 patients who took isolated tibial polyethylene insert exchange after mean 69 months-follow up of TKA, which was carried out from June 1991 to August 2003. Two cases were excluded on account of loss to follow-up. In all cases, isolated tibial polyethylene insert exchange was carried out from May 1998 to October 2008 in our institute and the mean follow-up period after operation was 48 (22-142) months. We evaluated the following clinical and radiologic aspects: range of motion, HSS score, average labor time, and BMI. Together, these factors were used in clinical evaluation while femorotibial angle and radiolucent line were used in radiologic evaluation. RESULTS: The average range of motion was 110.6 degrees and HSS score was 86.9 in follow up period. The average femorotibial angle was valgus 5.3degrees. The average labor time was 9.7 hours and BMI was 25.9. Although radiolucent line was found in 4 cases, there were all confirmed to be non progressive lesion less than 2 mm. Survival rate was 100% in Kaplan-Meier survival analysis. CONCLUSION: Selective isolated tibial polyethylene insert exchange can be the successful method for revision TKA in limited cases.

Treatment of Periprosthetic Supracondylar Femur Fractures Following Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: This study examined the outcomes of treatment in periprosthetic supracondylar fractures of the femur after total knee arthroplasty with the plates of internal fixation and retrograde intramedullary nailing using clinical and radiological methods. MATERIALS AND METHODS: Between August 1998 to May 2010, 24 cases of periprosthetic supracondylar fractures of the femur around the stem were selected and 18 cases of a stabled fracture without a loosening of the stem were chosen. The mean age was 69.1 (range 55-83) years and the mean follow period was 42.8 (range 14-142) months. In 18 cases, 8 cases who used a plate to gain anatomical alignment were categorized as group A and 10 cases who used retrograde intramedullary nailing were called group B. The union period, range of motion before fracture and last follow up, HSS score and tibiofemoral angle in both groups were compared. RESULTS: Radiographic union was obtained in all cases. The mean union period was 5 and 4.8 month in group A and B, respectively. In group A, the range of motion just before fracture was 120degrees and the last follow up was 93degrees. In group B, the range of motion before fracture was 124.5degrees and the last follow up was 96.8degrees. Although the range of motion in both groups had decreased appreciably (p0.05). The HSS score in group A was 87 just before the fracture and decreased to 79.8. The HSS score in group B was 85 before fracture and decreased to 81. The final HSS score at the last follow up decreased in both groups but the decrease and difference between the two groups was not significant (p>0.05). The coronal alignment in group A was 6.2 valgus just before the fracture and 4.4 valgus at the last follow up. The coronal alignment in group B was 6 valgus before the fracture and 5.2 valgus at the last follow up (p>0.05). CONCLUSION: In the treatment of periprosthetic supracondylar fractures of the femur after total knee arthroplasty, both an open reduction with internal fixation of the plates and retrograde intramedullary nailing showed good results in the clinical and radiological fields.

Meniscal Allograft Transplantation: Clinical Results and Recovery of Sports Activity / 대한스포츠의학회지

The purpose of this study was to evaluate the clinical results and recovery of sports activity in patients who received meniscal allograft transplantation. From December 1999 to May 2009, we selected 36 cases out of 38 cases who received meniscal transplantation using fresh frozen allograft. The mean age was 33.8 years (range: 17-50 years) and the mean follow up was 68.8 months (range: 12-142 months). Clinical results were evaluated with knee assessment scoring system (KASS), Lysholm knee score and International knee Documentation Committee. The information of quadriceps and hamstrings strength recovery was obtained using Tegner activity scale, Tegner activity score and Biodex system II (Biodex, USA), and it was used to evaluate the recovery of sports activity. The average KASS score was increased from 61.7 preoperatively to 83.8 postoperatively. The average Lysholm score was increased from 77.7 preoperatively to 87.7 postoperatively. Also, Tegner activity scale, Tegner activity score and the recovery of quadriceps and hamstrings increased at 1year after surgery. In knee joint position sense, the proprioception increased compared to preoperational count. We propose the meniscal allograft transplantation is one of a proper treatment after subtotal or total meniscectomy, which can significantly relieve pain and improve function of the knee joint.

The Results of the P.F.C(R) Sigma(TM) RP-F Knee System in High Flex Rotating Platform Total Knee Arthroplasty -Comparison of Preoperative Range of Motion less than 90degrees Versus more than 90degrees-

PURPOSE: The purpose of this study was to evaluate the clinical and radiological results of using the P.F.C(R) Sigma(TM) RP-F Knee System for high flex rotating platform-flexion total knee arthroplasty in 2 groups of patients with a preoperative range of motion (ROM) less than 90 degrees or more than 90 degrees, respectively. MATERIALS AND METHODS: From January 2005 to November 2006, eighty-two patients received the P.F.C(R) Sigma(TM) RP-F Knee System for high flex rotating platform total knee arthroplasty, and they were evaluated for a minimum of 3 years. We subdivided the patients into two groups: the preoperative ROM less than 90degrees group and the more than 90degrees group. The clinical results were assessed using the ROM, the Hospital for Special Surgery (HSS) score, the Knee Society Score (KSS) and the Western Ontario and MacMaster Universities Osteoarthritis (WOMAC) score. The radiological results were evaluated using the tibio-femoral angle and the presence of loosening or osteolysis of the components. RESULTS: The ROM increased in the two groups at the last follow-up. The mean ROM range at the last follow up was significantly increased more in the less than 90degrees group compared to that in the more than 90o group. The HSS score, KSS, and WOMAC score significantly increased in the two groups, but there was no statistical difference between the two groups. The tibio-femoral angle improved in the two groups. There was no aseptic loosening or osteolysis. CONCLUSION: The postoperative clinical and radiological measures were significantly improved using the P.F.C(R) Sigma(TM) RP-F Knee System on the short term follow-up, and especially for the patients whose preoperative ROM was poor.

Early Full Weight Bearing after an Autogenous Structural Bone Graft for Treating a Medial Tibial Bone Defect in Total Knee Arthroplasty: Minimum 5 Years Follow up Results

PURPOSE: We evaluated the results of early full weight bearing after an autogenous bone graft and metal screw fixation of severe varus deformity with a medial tibial bone defect in total knee arthroplasty. MATERIALS AND METHODS: From August 1996 to March 2004, 34 patients (43 cases) were selected for the analysis. The average age was 68 and the mean follow up period was 72 month. The clinical results were evaluated using the knee range of motion and the Hospital for Special Surgery (HSS) score. The radiological results were evaluated using the tibiofemoral angle, the presence of loosening, radiolucent lines and osteolysis and the component's location. RESULTS: The mean HSS score increased from 46 to 87 points on the final follow up. The mean range of motion was increased from 71degrees to 118degrees on the final follow up. The mean femorotibial angle showed varus deformity angulation (23.5degrees) at pre-operative surgery, 6.2degrees valgus deformity for the first 7 postoperative days and 6.1 valgus at the last follow up. CONCLUSION: These findings suggest that an autogenous structural bone graft and metal screw fixation has fine results and makes early ambulation possible for the patient who has severe varus deformity with a medial tibial bone defect.

Amorphigenin inhibits Osteoclast differentiation by suppressing c-Fos and nuclear factor of activated T cells / 대한해부학회지

Among the several rotenoids, amorphigenin is isolated from the leaves of Amopha Fruticosa and it is known that has anti-proliferative effects and anti-cnacer effects in many cell types. The main aim of this study was to investigate the effects of amorphigenin on osteoclast differentiation in vitro and on LPS treated inflammatory bone loss model in vivo. We show here that amorphigenin inhibited RANKL-induced osteoclast differentiation from bone marrow macrophages in a dose dependent manner without cellular toxicity. Anti-osteoclastogenic properties of amorphigenin were based on a down-regulation of c-fos and NFATc1. Amorphigenin markedly inhibited RANKL-induced p38 and NF-kappaB pathways, but other pathways were not affected. Micro-CT analysis of the femurs showed that amorphigenin protected the LPS-induced bone loss. We concluded that amorphigenin can prevent inflammation-induced bone loss. Thus we expect that amorphigenin could be a treatment option for bone erosion caused by inflammation.

Debridement Arthroplasty for Primary Elbow Osteoarthritis / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to analyze clinical and radiological results after debridement arthroplasty during primary elbow arthroplasty. MATERIALS AND METHODS: This study involved 25 primary elbow osteoarthritis cases that were treated by debridement arthroplasty from January 1996 to December 2004 with at least a 2 year follow up (mean: 41.3 months). Mean patient age was 45.5 years. Clinical outcomes were analyzed using preoperative and postoperative ranges of motion, Mayo Elbow Performance Scores (MEPS), and Visual Analogue Scale scores. Radiologic analysis was based on plain radiographs. RESULTS: Average flexion-extension arc improved from 72degrees ROM preoperatively to 110.5degrees postoperatively (p<0.001). Mean MEPS was 89.5 points preoperatively and increased postoperatively (p<0.05). Humeral fenestration size decreased from 27% to 20.5%. Bony spurs of the olecranon and coronoid process recurred in 8 cases. Postoperative LOM was found to be associated with spur recurrence (p<0.05). CONCLUSION: Debridement arthroplasty may be recommendable for primary elbow osteoarthritis as it reduces pain and improves functional outcomes, including range of motion. Spur recurrence was found to be associated with a reduced range of motion.

Diagnosis of Infected Total Knee Arthroplasty

Infection of a knee prosthesis leads to specific problems in relation to the function of the knee joint. Making an accurate and early diagnosis is the first step in effectively managing patients with periprosthetic joint infection. At the present time, the diagnosis remains dependant on clinical judgment and reliance on standard clinical tests, including serologic tests, analysis of the aspirated joint fluid and interpretation of the intra-operative tissue and fluid test results. The screening test results that may suggest the possibility of infection include elevation of the erythrocyte sedimentation rate and/or the serum C-reactive protein level at more than three months after an arthroplasty. Cultures of the aspirated joint fluid can be especially helpful for patients who have symptoms suggestive of infection. The joint fluid cell counts may also be helpful, but Gram staining of the joint fluid has poor sensitivity and specificity. Intra-operative culture should not be used as a gold standard for periprosthetic infection owing to the high percentages of false-negative and false-positive cases. The criteria for diagnosing infection on the basis of frozen sections of implant membranes have not yet been standardized, but in many laboratories, more than five neutrophils per high-power field in five or more fields have been found to be suggestive of infection. Combined with clinical judgment, the total white cell count and percentage of neutrophils in the synovial fluid more accurately reflects periprosthetic joint infection. When this is combined with hematologic exams, infection can be safely excluded or confirmed.

Complications of Femoral Peritrochanteric Fractures Treated with the Gamma Nail

PURPOSE: We analyzed the complications of femoral peritrochanteric fractures treated with the Gamma nail to reduce its complications. MATERIALS AND METHODS: We evaluated the complications among the 96 patients who were treated with the Gamma nail from January 2000 to May 2005. Mean follow-up period was 17.8 months and mean age was 75.2 years. We analysed the relationship between the complication and the fracture pattern, postoperative reduction status, position of the lag screw, bone density, displacement and tip-apex index (TAD). RESULTS: The complications were presented in 12 cases (12.5%). Cut-out of lag screw were in 5 cases, varus deformity with short lag screw in 2 cases, metal breakage of distal screw in 1 case, breakage of drill bit intraoperatively in 1 case, superficial infection in 2 cases and deep infection in 1 case. 5 cases (4.2%) were required reoperation. All of the cut-out of lag screw showed increased TAD (tip apex distance) above 25 mm. CONCLUSION: To reduce the complications of the Gamma nail, we need exact surgical technique, good positioning of the lag screw and choice of appropriate length for the lag screw.